1. Chest pain workup

2. History
Pt is a 28 year-old white male who presents to ER following a small knife wound to the chest sustained in a mugging.
c/c: “I feel like I’m dying.”
HPI: Pt arrived in ER with a 1 inch stab wound sustained to the left side of his chest which doesn’t appear to have penetrated very deeply. Pt reports he was stabbed with a knife by a mugger while outside an ATM. Pain is rated 10/10. Pt has not experienced much in the way of blood loss but he feels terrible, is breathing rapidly, and is very weak. ER survey was conducted and Pt was started on IV fluids via 2x large bore IVs.

3. History, continued PMH: None.
PSH: Rotator cuff surgery on L shoulder 4 years ago.
All: NKDA.
Meds: Fish oil supplements.
Fam: Father (HLD).
Soc: No Tob, 5-7 drinks EtOH/wk, no illicit drug usage.
ROS: +Chest pain, +SOB, +cough; no hemoptysis, no abdominal pain, no nausea, no vomiting, no diarrhea, no constipation, no blood in stool, no pain on urination.

4. Physical
VS (abn only): RR 21, HR 115, BP 58/78 on admit (improving with free-flow fluids and currently at 74/97).
HEENT: WNL.
Neck: Evident JVD (increasing on inspiration), no carotid bruits.
Chest: No tenderness, breath sounds clear and equal bilat.
Heart: Distant heart sounds, tachycardia, normal rhythm, normal S1/S2.
Abd: Soft, non-distended, non-tender, BS+.
Extr: No edema, peripheral pulses weak and symmetric.

5. Any Initial Differentials so far?
*Note: while there are obvious aspects of a trauma or shock work-up with this Pt, what I want you to focus on is the underlying clinical pathology you think is present.
That is to say, what’s causing this?

6. Differential diagnoses
Ccommon causes of chest pain include:
Aortic dissection
Cardiac tamponade
Massive hemothorax
Pleural effusion
Pneumothorax
Pulmonary embolism

7. So, which initial imaging/labs should we get?

8. Initial imaging/labs
By far the most important imaging/labs in this work-up are:
ECG
Echocardiography
CXR
CBC/electrolytes
ABG
Continue monitoring VS
This is not to say you couldn’t order additional tests/labs; however, these imaging/labs will:
Cover the differentials in our chest pain work-up
Focus on the most serious (i.e. life-threatening) targets in our chest pain work-up (the ones which clinically you cannot afford to miss)
Help to conserve costs (typically, both our Pt and our attending will not be happy if we order every test under the sun)
*As an aside, obviously in any instance where there has been a stabbing, etc. which arrives, police should be notified

9. imaging/Lab results

10. Cxr result
Take a quick precursory glance to see if there’s anything abnormal:
Are the lungs full (i.e. not collapsed) and clear of blood/fluid?
Is there any mediastinal shift or widening?
How about the size of the heart? (Normal is <1/2 chest width)
What we’re looking for generally is to be able to rule out some of our differentials

11. Cxr result, continued This CXR is clearly abnormal:
Lungs are largely obscured by the heart but there does not appear to be either a pneumothorax or pleural effusion.
There is no mediastinal shift (i.e. no tension pneumothorax) or widening (no aortic dissection).
Outline of the heart is hugely enlarged and globular in shape. There is obviously some kind of effusion present here.

12. Echo results
Echo shows ventricular diastolic collapse

13. ECG RESULTS So what does our Pt’s ECG indicate?
First look at leads II and V5
Does this look like a normal ECG tracing?
Next, note the changes in anterolateral leads V3-V6

14. ECG RESULTS, continued
Looks like we have notable QRS alternans (alternation of QRS amplitude)
Look at leads II and V5 – see how the QRS height fluctuates?
Hint: QRS alternans is typical of the problem we’re dealing with

15. Differential diagnoses, revisited
So, whittling down our differentials, we have:
Aortic dissection
No mediastinal widening, no ripping/tearing chest pain radiating to back.
Cardiac tamponade
Triad of hypotension, muffled heart sounds, and JVD (especially increased JVD on inspiration), in addition to ventricular diastolic collapse on Echo and CXR showing a massive globular-shaped heart (due to blood in the pericardium).
Massive hemothorax
There is definitely blood here, but it appears to be confined to the area around the heart.
Pleural effusion
No apparent blood in the lungs.
Pneumothorax
No air in chest cavity, no mediastinal shift.
Pulmonary embolism
SOB; however, no fever, no DVT risk, 0/3 on Virchow’s Triad (no hypercoagulable state, no endothelial damage, and no stasis).

16. So what’s our final diagnosis?

17. Final Diagnosis What we’re dealing with here is cardiac tamponade.
How do we know this? Primarily due to the following triad:
Muffled heart sounds
JVD (and Kussmaul’s sign – increased JVD with inspiration), and
Hypotension
Along with:
Tachycardia
Narrow pulse pressure
Ventricular diastolic collapse on Echo
Enlarged, globular heart on CXR
Pt hx of stab wound to chest

18. Cardiac tamponade
Cardiac tamponade occurs due to an excess amount of fluid in the pericardial sac which leads to:
Decreased filling of the heart
Low stroke volume (and narrow pulse pressure)
Decreased cardiac output
Cardiac tamponade is typically due to:
Pericarditis
Stab wounds
Malignancies
So, how do we treat cardiac tamponade?

19. Cardiac tamponade treatment
Management of cardiac tamponade is a relatively simple process to remember:
Hospital admission with continuous cardiac monitoring
IV fluids to promote volume expansion (increasing CO), and
Pericardiocentesis (stick a needle into the pericardium and suck out the excess fluid)

20. In summation So, to recap remember a few key things:
Think cardiac tamponade when you see its tell-tale triad of:
Muffled heart sounds
JVD (and Kussmaul’s sign – increased JVD with inspiration), and
Hypotension
Also remember cardiac tamponade is a potential occurrence following:
Pericarditis
Stab wounds
Malignancies
Cardiac tamponade is managed with:
IV fluids to promote volume expansion, and
Pericardiocentesis to remove the excess fluid

21. bibliography American Heart Association Cancer Dundee Quizzes
Available at:
Cancer Dundee Quizzes
Available at:
Heart Pearls
Available at: